Endoscopic ultrasound-guided liver biopsy using a single-pass, slow-pull technique with a 19-G Franseen tip fine-needle biopsy needle: A prospective study.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided liver biopsy (EUS-LB) is considered to be safe and effective. Commonly a 19-G fine-needle aspiration or biopsy needle is used. But, the results vary with different techniques that are used. Herein, we report the results of liver biopsy with a single-pass, three actuations (1:3) using the slow-pull technique. METHODS: In this prospective study, 50 consecutive patients with indications for liver biopsy underwent EUS-LB with a 19-gauge fine-needle biopsy (FNB) needle from both right and left lobes. The primary outcome was the adequacy of the specimen for histological diagnosis. Total specimen length (TSL), longest specimen length (LSL), complete portal tracts (CPTs) and comparison of these outcomes between the left lobe and right lobe specimens were secondary outcomes. Adverse events (AEs) were also measured during this study. RESULTS: Adequate tissue for histological diagnosis was obtained in all 50 patients (100%). The median number of CPTs was 32.5 (range, 11-58), while the median of TSL was 58 mm (range, 35-190) and the median LSL was 15 mm (range, 5-40). There was no significant difference in CPTs, TSL and LSL between left and right lobe biopsies. There was no major complication; one of the patients (2%) had bleed from the duodenal puncture site, which was managed endoscopically without the need for blood transfusion. CONCLUSIONS: Endoscopic ultrasound-guided liver biopsy using a 19-gauge Franseen tip needle with a single pass, three actuation (1:3) and slow-pull technique provides adequate tissue yield and has a good safety profile.

Nonsecretory Paraganglioma in Cavernous Sinus Masquerading as Meningioma.

BACKGROUND: Paraganglioma in cavernous sinus is a rare entity often misdiagnosed as meningioma or schwannoma on radiology. The embryological origin, from cells of neural crest, does not explain the location per se. Because of its highly vascular nature and close proximity to the carotid artery, surgical excision is a challenge. We herein report the first case of cavernous sinus paraganglioma, without the characteristic "salt and pepper appearance," excised near completely by the subtemporal approach. CASE DESCRIPTION: A 30-year-old woman without a history of any comorbid conditions, particularly hypertension, presented with a 6-month history of progressive headache and double vision. She exhibited upward gaze palsy and hypoesthesia over the right half of her face. There was no papilledema and proptosis. Radiologic imaging revealed an extra-axial T1-weighted isointense, T2-weighted hyperintense lesion with homogenous intense contrast uptake in right parasellar region encasing cavernous internal carotid artery. Furthermore, the tumor was extending along the superior orbital fissure. Suspecting a cavernous sinus meningioma, we performed near-total excision via a subtemporal approach. Postoperative recovery was uneventful, and patient was discharged on fifth postoperative day. The histopathology and immunohistochemistry were consistent with paraganglioma. The patient underwent adjuvant radiotherapy and is under our outpatient follow-up. CONCLUSIONS: Paraganglioma must be considered in the differential diagnosis of parasellar tumors, even when secretory symptoms are absent. The radiologic findings are obscure, and it is difficult to differentiate it from more common tumors of this region such as meningioma, schwannoma, and pituitary adenoma. Surgical excision followed by radiotherapy is the mainstay of management.

Malignant mediastinal lymphadenopathy detected by endoscopic ultrasound and guided fine needle aspiration in patients with resectable pancreaticobiliary cancer.

BACKGROUND: Resection surgery for pancreaticobiliary malignancies carries significant morbidity and mortality. Hence, preoperative assessment to exclude unresectable disease is mandatory. CT abdomen is the primary modality for staging of pancreaticobiliary cancers. However, some patients have malignant mediastinal lymphadenopathy (MML), which may be detected on endoscopic ultrasound (EUS) but not on CT scan. METHODS: We prospectively evaluated 75 consecutive patients (median age 54 years: 44 men) with a diagnosis of resectable pancreaticobiliary cancer (carcinoma gallbladder, carcinoma pancreas, cholangiocarcinoma, or periampullary carcinoma) for the presence of MML using EUS by an experienced endosonographer. If a lymph node had one or more features suggestive of malignancy, i.e. size exceeding 1 cm, hypoechoic appearance, a round shape, and regular margins, it was subjected to EUS-FNA. RESULTS: In seven (9.3%; 95% confidence intervals: 3.8% to 18.2%) of the 75 patients, EUS revealed enlarged mediastinal lymph nodes. The location of these lymph nodes was subcarinal in three, paraesophageal in two, and paratracheal in one patient; another patient had lymph nodes at two sites, i.e. the subcarinal and aortopulmonary window. In four of these seven patients, FNA documented the presence of MML. The overall rate of pathologically proven MML was 4/75 (5.3%; 95% CI [1.4% to 13%]). CONCLUSION: EUS-FNA diagnosed MML in 5.3% of patients with pancreaticobiliary cancer. It may be useful to consider EUS assessment in patients with otherwise resectable pancreaticobiliary malignancy.

Percutaneous computed tomography-guided aspiration and biopsy of intrathoracic lesions: Results of 265 procedures.

CONTEXT: Percutaneous computed tomography (CT)-guided needle aspiration and biopsy technique have developed over time as a method for obtaining tissue specimen. Although this is a minimally invasive procedure, complications do occasionally occur. AIMS: The aim of the study was to evaluate the diagnostic yield and complications of 265 percutaneous CT-guided aspiration and biopsy procedures performed on various intrathoracic lesions. SETTINGS AND DESIGN: Data of percutaneous CT-guided aspiration and biopsy procedures of intrathoracic lesions performed over a 4 year period were retrospectively analyzed. SUBJECTS AND METHODS: Procedure details, radiological images, and pathological and microbiological reports were retrieved from radiology records and hospital information system. Technical success, diagnostic yield, and complication rates were calculated. RESULTS: Total 265 procedures were performed for lung (n = 179), mediastinum (n = 73), and pleural lesions (n = 13). Diagnostic yield for lung, mediastinal, and pleural lesions was 80.7%, 74.2, and 75%, respectively, for core biopsy specimens. Major complication was noted in only one procedure (0.4%). Minor complications were noted in 13.6% procedures which could be managed conservatively. CONCLUSIONS: Percutaneous CT-guided aspiration and biopsy procedures for intrathoracic lesions are reasonably safe with good diagnostic yield. Complications are infrequent and conservatively managed in most of the cases.

Ampullary neuroendocrine tumor presenting with biliary obstruction and gastric outlet obstruction.

Neuroendocrine tumors of the ampulla of Vater are extremely rare cause of extrahepatic biliary obstruction and further rarer cause of duodenal obstruction, and only a few cases have been reported in the literature. Herein we report a case of ampullary neuroendocrine tumor in a 75-year-old woman who presented with biliary obstruction and gastric outlet obstruction palliated with metal biliary and duodenal stenting with relief of jaundice and vomiting at 1 month of follow-up.